Episode 77: Decoding Dementia

Welcome to MetPod, the audio podcast from the department of internal medicine at AFMC. We have been doing these podcasts on various topics in the speciality of medicine and we have also gone on to discuss some important relevant issues in the allied specialities of dermatology, psychiatry and even anesthesia. The whole aim is to bring well-validated content which is good for undergraduate students, postgraduate residents and young doctors in peripheral hospitals where they often find it very difficult to get such a reliable source of information be it for addressing questions in their exams or while treating patients. Continuing with this task, now we move on to our very important topic which is of great relevance as far as clinical practice is concerned, be it at primary care or subsequent in speciality practice and that happens to be of forgetfulness or dementia. To discuss this very important topic, today we have with us Colonel R. Srinath who is a neurologist and has been a senior faculty both at the same department that we are bringing this podcast to you from at AFMC and also at the command hospital in Bangalore. So, welcome Srinath. Thanks a lot sir. At the outset, I would like to thank my mentor and my teacher for giving me an opportunity to do this and I would like to possibly share my knowledge whatever I have in this present discussion. Thank you again sir. Right. So, this topic is something that we have been talking about in our usual conversations in the department or when we teach postgraduate students and more important than that is the fact that we often encounter this problem right there at our homes. Our elderly parents or relatives often come with these issues and even for that matter even at a younger times than elderly, we have noticed a kind of forgetfulness that creeps in and as physicians, as neurologists, we are left to wonder whether it is a disease or it is just that usual forgetfulness which we often laugh off and make jokes about if somebody is very forgetful. So, my request to you is as a very senior faculty and having been experienced neurologist to make this complicated issue simplified for our students, so that tomorrow when they encounter a patient of this nature, they do not miss those important issues that they need to address, right. So, while we discuss this topic, I first want you to tell us how bad is the problem? Is it very relevant, is it very pertinent for our students to even know this topic? Yes. So, as you rightly brought out, in fact, most of our healthcare setups whether it is primary, secondary or tertiary, they come across patients who presents themselves that I have some forgetfulness that is one subset, then there is another subset of patients who brought by the relatives that they have some issues. So, coming to firstly to the question which you had asked is it so bad, it is definitely very bad. So, because as per the data available to the world as well as in the Indian literature, it is possibly estimated that there will be at least around 75 million people in the year 2030 will have some form of dementia whether it is Alzheimer's or frontotemporal dementia or vascular dementia, which is quite a big burden and we should also remember that most of the cases of, many of the cases of dementia are missed in the clinical practice because as we always talk of the tip of the iceberg, so if it is around 74 million entire world in 2030, it may be another 50 million which we can easily add and it is around 100 million people who are suffering from dementia at any time in 2013 in the world, which is a big problem and in Asian setup it is almost 40 million which is quite a big burden which is almost two thirds of the people who are diagnosed with dementia. And coming to India alone, it has been found that as per the data available, it is estimated that by the year 2050, there will be at least around 15 million people above 60 who will be having some form of dementia or the other mild moderate density. Hence, the reason why we should know about this is dementia is one of those conditions. If it is diagnosed early, if it is possibly found early, there are means and ways where we can tackle it because some of the forms are reversible forms, some of the forms are reversible, both have got their own treatment potentials be it less or whatever means. So, that is why it is important to know that the problem of dementia it is important to understand itself. Right. So, when we talk about dementia and we go back to the basics, it is all about memory and we have learned during our physiology days and then subsequently in medicine that memory gets built up in the brain because of its neural network and the various circuits that are there inside. So, if you could just simplify this complicated physiology in our brain. Yes. So, we have what is more important as opposed to the earlier maybe a few 20, 30, 40 years back when there was a concept of lobes, different lobes frontal lobe, temporal lobe, pariet lobe, oxbit lobe, they work independently, last about say 15, 20 years they have come up with the concept of circuits or networks. Each lobe of the brain is interconnected with each other as well as on the other side. So, what we have is the functional circuits or networks in the brain, we have five functional networks, I will name each one of them. The first one not necessarily in that order is a perisilvian network which is around the perisilvian fissure which is from inferior frontal and superior temporal, which is a language network, we know the Broca Seria and Wernicke Seria living there. So, that is a language network which is important for the language which is a cortical function. Then another thing is a limbic network, the limbic system wherein there is retentive memory is there, emotions are there, the papas circuit is formed there that is mainly in the temporal loop. Then another circuit, the third circuit is the frontal parietal region, wherein it is important for spatial recognition as well as the cognition. So, parietal lobe as we know is a sensory integration center, frontal lobe is important for cognition and behavior which was a third one. The fourth one is a prefrontal network, the prefrontal network is slightly ahead of the frontal lobe which is important for behavior as well as attention, so attention span is important. When we discuss memory we can tell about that there are certain aspects of the frontal lobe which are involved in the attention span. Then lastly the temporal occipital region, the temporal occipital region is important for recognition of face and objects. So, just to summarize one is a perisilvan network, then occipitotemporal network, prefrontal network, then frontal parietal network and limbic network. These are the networks which are important for us in functioning day to day activities including sensory motor as well as cognition. Right, so these are the networks and you mentioned how these areas are so important for ensuring that memory is sort of same and then can be utilized. So what about the various storage sites, where does the memory actually get stored and so maybe these areas that you mentioned you can highlight those aspects as well. So another important aspect which I have I want to mention is the human brain is unique from other brains which includes like the human brain size is maybe smaller than a brain of an elephant. But human brain is unique because it has got something called association cortices, there is frontal association cortex, parietal temporal occipital. So these association cortices are the things which differ which are there present in human brain which is not there in primates. So the memory we broadly divide memory into short-term memory and long-term memory. The short-term memory is a thing which we call working memory which lasts for a few minutes. A simple example is whatever we suppose we listen to some telephone number if somebody enumerates a telephone number, then we listen to that and we go and dial the telephone number and after about 5 or 10 minutes we are unable to remember the telephone number that is the short-term memory. In the long-term memory there are two types, one is the immediate memory and another is the long-term memory. So the storage sites important places of storage site is for short-term memory which is a working memory is a frontal lobe, for the long-term memory for the immediate memory it is a medial temporal lobe, for the remote and semantic memory it is a lateral temporal lobe. Apart from this there are certain other types of memory which for example is something called procedural memory. The procedural memory is something like if a person once he learns how to cycle or how to swim even if he does not swim for say about next 10 years or even if he does not cycle for next 10 years, he is still able to do that, that is what is procedural memory and this procedural memory has got its role in the association cortices as well as in the cerebellum also. So the procedural memory is very very important and describing about this very very important aspect what is important in memory is the role of association cortices and role of the other gray matter structures, for example the something like stratum, stratum is a part in the gray matter in the bracyl ganglia gray matter they are also again involved in some parts of procedural. So just to summarize there is something called working memory, there is something called remote memory in the remote memory there is something called semantic memory and there is something called immediate. Right so this is very fascinating actually to understand and probably localize lesions in dementia to understand where what is stored becomes so important when you actually examine a patient for memory. So that is interesting, now we mentioned term when we were initially introducing the topic as what we call in general working or talking language as forgetfulness which for a layman sounds like forgetting something which happens all the time to all of us to something that a neurologist would call dementia. So what is the difference in these two terms? Yes, so there are two different aspects here one is forgetfulness in simple terms is actually forgetfulness is a medical term is amnesia in fact there is an ICD code also in that the ICD 10 code is R 41.3 wherein they mention it as other amnesia the actual definition of forgetfulness or amnesia is loss of memories which may include facts information or experiences it may be short term it may be long term it may be due to any specific reason or it may be due to stress or it may be due to any other reason. But forgetfulness may eventually lead to dementia but and subsequently but not all forgetfulness actually results in dementia. Dementia per patient may definitely have forgetfulness but not all forgetfulness will lead to dementia. Now the simple difference between forgetfulness and dementia is in the dementia in the diagnostic statistic manual DSM 5 definition it includes the involvement of the 6 cognitive domains any one involvement at least if one is involved we define it as dementia one of them is one is learning and memory another is language another is executive function complex attention perceptual motor and social cognition. Among these cognitive domains if any one of the cognitive one or more cognitive domain is involved and which results in significant impact in the qualities or activities of daily living and which should not be explained by ongoing delirium or any other cause then we actually diagnose it as dementia. So dementia should be have a specific for specific symptoms wherein which affects any one of these domains whereas forgetfulness can be short term or it can be due to some secondary cause. For example if a person is possibly intoxicated with some ethanol or if a person is having fever if a person is having some stress if a person is having some insomnia if a person is not well then also he may have some forgetfulness very much of eagerness to remember things also because of stress or anxiety may also result in some short term forgetfulness. So just to summarize forgetfulness may be a symptom of dementia but not our forgetfulness is due to dementia right this is very resting and in fact it is a new learning for me as well and in fact so putting it in the neurology parlance only I am thinking that to this sounds like seizure and epilepsy so when we approach seizure it could be due to different reasons but then all epilepsies also have seizures but then all seizures are not epilepsy so I think somewhat in similar lines. Now when we talk about dementia we also talk about dementia we talk about pseudo dementia we talk about the minimal cognitive impairment or like you mentioned just now which is a sort of diagnosis of exclusion for dementia that is delirium so all these terms are very specific and they need to be defined so if you could just simplify them for our audience. Yes one very important before understanding dementia is we should understand the concept of pseudo dementia pseudo dementia is usually it is due to some psychiatric problem or some behavioral issues it may be due to depression it may be due to anxiety it may be due to some personality disorders or it may be just because of the person's nature itself it may be possibly nothing also such to give an example we have two sets of patients one patient comes to the clinic he may be a high achiever and he comes to the clinic and says that I yesterday I forgot something and I am possibly having dementia please check when you examine him what we realize is his insight is absolutely well preserved because he is aware of his condition and you will not get anything in his examination neither in general examination nor neurological examination every investigation will be normal he will be classically fitting into pseudo dementia sometimes there will be exaggeration of symptoms also classically dementia patients they themselves never come to the hospital they are brought by their relatives that they are lost somewhere they are being found possibly interacting less or they are possibly forgetting things and there are some mishaps in the house like they have switched on the gas or some lost their keys or credit card something like that and when you ask the patient of an actual true dementia he will not have an insight he will say an absolutely normal so that is more difficult to diagnose because the individuals will bring relatives will bring and it will be very much clear so there is a catch here that we should not ignore a patient who himself comes and says that I have forgetfulness just by saying a pseudo dementia you have to thoroughly evaluate and keep that person under follow-up because eventually he may or may not develop and also a patient whenever he comes with forgetfulness you have to look at the element of pseudo dementia but also possibly keep a watch for dementia so just to summarize in pseudo dementia the insight is preserved there is exaggeration of symptoms and usually it is due to psychiatric symptoms all due to anxiety or personality disorders and normally there may be episodes of restlessness and some episodes of delirium whereas in a case of dementia insight is not there the individual feels that he is normal generally he does not himself present he is brought by the relatives and of course there may be sleep wake cycle difference to be there in a case of true dementia and coming to the second question which you had asked regarding dementia and delirium now a delirium can occur in a case of dementia intermittently but both of them are different because delirium is a short is a duration of abnormal behavior with fluctuating levels of consciousness a patient of delirium may have some abnormal behavior it may be hyperactive it may be hyperactive whenever the patient is having hyperactive delirium he may be dull it may appear that he is having dementia but there are episodes where he may be having hyperactivity also in between those two periods he is absolutely normal so that is the difference between delirium whereas dementia it is a slowly progressive condition initially he will be ok and over a period of weeks months it will progress and another important thing is the sleep wake cycle is disturbed in a case of dementia because there will be sundowning there will be symptoms increase symptoms in the evening whereas in cases of delirium the sleep wake cycles unless it occurs in the night it is not disturbed and patients of dementia usually are over a period of time in the progressive dementias their campness their personal hygiene they will all be affected whereas a patient of delirium if it is only for a short duration his campness and and personal hygiene will be normal and lastly in the case of delirium there will be some inciting cause or something which has acutely occurred for example some febrile syndrome some pneumonia some meningitis or some other condition wherein he is admitted in the hospital in the ICU maybe ICU psychosis ICU delirium whereas a case of dementia it occurs in a normal social setting with some background which gradually progresses. And the third question which you had asked was that the in what is the difference between dementia and mild cognitive impairment it is very important to know about the mild cognitive impairment because mild cognitive impairment is a precedent for a person to develop dementia mild cognitive impairment again the definition is same as dementia except that the activities of daily living is not affected. One of those cognitive domains may be affected which I have mentioned earlier however it does not affect the activities of daily living and he will be only be mildly affected he will have mild forgetfulness he will have episodes wherein he is lost somewhere but rest of the times he is not so it is important to diagnose at this stage because the medications available for dementia if given early can possibly delay the onset of progressive dementia. Right so that is very lucid description and understanding these topics differently is very important now as physicians any progressive condition which is difficult to treat and relentlessly progressive like dementia has to be differentiated from conditions which can be treated and are reversible and so there are certain conditions where patient can present with reversible dementia and as physicians it is very important and so I want you to highlight those aspects which will and in fact which all our listeners should remember when they actually encounter a patient with dementia. So I will have to add here that there are two things which I have to add here one is while we evaluate dementia we should know about two things here one is dementia which are treatable or reversible and another thing is dementia as Sarah mentioned one is rapidly progressive dementia. I will first cover with the rapidly progressive dementia rapidly progressive dementia there is exactly no time bound in that dementia which progresses over weeks to months because we call it as rapidly progressive that means a patient who had a normal level of physical activity normal activities of daily living he rapidly progresses and becomes fully dependent for all his activities of daily living over weeks with involvement of all this at least one of these cognitive domains we call it rapidly progressive dementia. Now what is the importance of knowing this rapidly progressive dementia there are certain of those diseases which can be life threatening for example there are certain diseases which like prior on diseases is one of the important diagnosis for rapidly progressive dementia for which unfortunately still now neurological science does not have any treatment. Then there are other treatable forms of rapidly progressive dementia like autoimmune encephalitis wherein there may be some remote illness and there may be due to some effect because of the antibodies which have formed and which can be treatable with steroids or which can be IVIG or with methylprednisolone or with say retoxinab or something that is one. Another thing is there may be some harboring infection which may be there which may possibly present like this and there are sometimes other conditions wherein the progression may be rapid but it can be halted with adequate treatment. So, these are the concepts of rapidly progressive dementia. Once a person progresses rapidly in a case of dementia it is important to know and quickly diagnose because if there is a therapeutic potential in the form of autoimmune encephalitis or some infection it can be treated. Coming to the second aspect of the question the what is the what is the importance of knowing about the diagnosis or approaching a dementia because there are certain forms of forgetfulness and dementia which has got a treatment potential. Just to name a few the list is long there are certain conditions which includes which can be simple as simple as a nutritional deficiency in the form of vitamin B12 deficiency which can present with it can also present with it may not present with rapidly progressive dementia, but it can progress it can present with progressive dementia which can be treated. Then B12 always we know it coincides with folate in their metabolism folate efficiency also can sometimes present with this. Then certain endocrine infections endocrine conditions like hypothyroidism, hypoparathyroidism they can also present like this. Then there are certain conditions especially hypercalcemia in the case of hyperparathyroidism can also present which abnormal behavior and sometimes bonus also. Then certain other conditions certain infections certain infections like meningitis sometimes and where in chronic meningitis can also present. And then there are certain other conditions like CNS vasculitis systemic lupus erythematosus these are certain of the vasculitis conditions which can present which has got a treatment potential and one other important conditions which can present with gait abnormality frontal lobe features and then urinary symptoms which we call normal pressure hydrocephalus. That has all got to treatment potential because once ventricular peritoneal shunt is put in place the patient may become asymptomatic. Then sometimes even though these days it is less neurocephalus which can present again with cognitive decline and it has got a treatment potential dementias and HIV infections as we know HIV AIDS complex they can also present with dementias now the present antiretroviral therapy available with advances they can also be treated. And lastly the conditions like which has got multi system involvement like Wipple's disease which has got gastrointestinal symptoms, immunological symptoms, neurological symptoms they can also present with the treatment treatable dementias symptoms. And sometimes rarely there can be a space occupying lesion which may be present intracranial space occupying lesion the frontal lobe temporal lobe which may present with temporal related delayed memory problem or in the working memory problem so that may be also the cause. So, it is important to know the rapid progression dementias we have to diagnose fast for treatment potential and also any reversibility which can be correct. Right. So, that is something that one should revise and like you said the list is very long of these treatable dementias but we should try and look for them whenever we have a patient. Now, moving on as a patient if I consider myself or somebody who is worried that can I get dementia like you said the risk of getting dementia is so high in our population we see so many cases now. So, now I am nearing mid 50's so I am worried that can I get dementia so what makes me more prone to it and two can I pick it up early these are things that I would like to know. Yes. So, to the question can I get dementia there are certain known modifiable and non modifiable risk factors for dementia. I will first come to the modifiable risk factors which are more amenable to for modification. There are certain modifiable risk factors which increases the risk of dementia there are certain modifiable things which decreases which is important to know I will tell first about the positive things. There are certain things certain risk factors which if it is there that helps in reducing dementia the most important thing is years of formal education. It is known that number of years of formal education once it increases it reduces the chances of dementia that is one. Another thing is physical activity the person is physically active because one of the important risk factors for dementia is midlife obesity midlife hypertension. So, physical activity will definitely reduce the chances of somebody getting hypertension or obese in the midlife. Then Mediterranean date as we know which includes lot of vegetables and certain cereals and all that is also found to have reduction in not only in dementia in many other atrosclerotic diseases. Then cognitive training that means cognitive training means as a professional any person who is actively employed we do not actually require any cognitive training. Once we are cognitively active once you are mentally active keep yourself active the chances of dementia are very less. Then it is also found that social engagement once a person is engaged socially at various phases of life and not get isolated that is also reduces the chances of a person getting dementia. Here when I say dementia it is I am talking about progressive dimensions which I will be enumerating after I finish this. Now coming to the the red things that is the things which increases the chances of a person getting dementia, traumatic brain injury anytime in the person's life especially repeated traumatic brain injury. As I have explained about the concepts of circuits whenever there is a traumatic brain injury there is a break in the circuits all this. So whenever there is a break in the circuits whenever the re-circuitary or regeneration is difficult to occur after the midlife that is one of the risk factors. Then midlife obesity which I was mentioning then midlife hypertension and then smoking status nicotine in any form it is known to increase the chances of person getting dementia and then midlife diabetes and any patient who has got sleep disturbances they are also known to have dementia. Now there are certain non-modifiable risk factors which of course one is of course non-modifiable risk factors is a family history of dementia there are certain autosomal dominant dementia syndromes which if a person is there it is not necessary that his siblings or his descendants may have but definitely there is a risk is higher and apoe deficiency it is known to have about 5 percent 7 to 8 percent of chances of them having dementia. So then there are certain risk scores which are there which can possibly estimate a person whether he gets dementia or not that is whatever age there is a one of the one of the accepted score is CAIDKED score which is a cardiovascular risk factors aging and incidence of dementia which has various sub heads in that one is a age then another is education then gender blood pressure body mass index total cholesterol and physical inact physical activity inactivity. So there is a scoring and as the score raises the 0 to 5 dementia chances are less than 1 percent and as the score total score raises about 10 the chances of dementia will be 10 percent. So here also if you can observe here the parameters here are one is age of course as one crosses 70 75 the chances of some form of a treatable non-triple dementia will be higher definitely education is important here then blood pressure BMI total cholesterol and physical activity inactivity. So these are the things which I have already mentioned which are important. Now I want to add here in the same discussion that the risk of dementia or do I get dementia again if somebody gets a treatable dementia it is not that bad. Then what are those irreversible or progressive dementia known progressive dementia are first is Alzheimer's disease which is actually one of the things which even though there are certain therapies available but it is not completely curable. The another thing which is well known is a vascular dementia wherein a patient will have vascular risk factors there will be step platter pattern of progression and he will have other domains of involvement also and then his frontotemporal dementia wherein they will have behavioral abnormalities with frontal and temporal lobe cognition involved and other than that there are certain other dementias which can also present like Parkinson's disease can also have some Parkinson's related dementias and other minor forms of dementia. So one should understand that to prevent dementia just to summarize physical activity prevention of hypertension diabetes dyslipidemia and socially being active and then of course good number of years of formal education these are the things which will prevent a person from having dementia. So I think this is very important to understand because we will also and that score system that you said can actually help us understand whether we are at risk or not and the positive things that you mentioned I think can be used as a primordial or primary prevention of dementia in a long term. Now lastly coming to the question of managing such patients or approaching these patients once they come to us if you could just briefly highlight the important aspects not going into the specifics of it that how do you approach such a patient. So there are only very important to note that whenever a person presents with either forgetfulness or dementia or whatever then the most important thing is you should have a reliable history the history may be given by the patient or at least you should always ensure that some next of kin who stays with the patient most of the time he should be available to give a proper history that is first point of approach. The second point is when you take the history please understand that we should also rule out we should there only itself rule out the possible coexistence of delirium in this case and also pseudo dimension that is a second point. The third aspect is once we are sure that it is possibly not pseudo dementia it is not delirium and we have to completely thoroughly do the examination where you will get settle hints we may get if there are some extra individual features in the examination it is possibly subparticle dementia which is Parkinsonian dementia or if there are some other issues like cortical symptoms in the form of Vepraxia, Inmosia, Ephesia then there may be possibly cortical dementia. Once you examine the patient once you have sure that it is not pseudo dementia it is not delirium it is dementia the most important aspect is we have to look for treatable cause even though it may be suggestive of progressive dementia we should still do certain basic investigations which includes of course hemogram along with the hemogram I forgot to mention in my previous treatable thing hyponatremia is a very very important aspect of a treatable dementia which most of us encounter in our clinical practice either due to medications like some of the diuretics as a diuretics or sometimes some of the antipsychotic drugs or less oral intake of salt. So in the investigations like apart from the hemogram where we look for evidence of sepsis then also look for electrolytes especially sodium then thyroid profile then viral markers and then of course we have to look we have to do a neuroimaging and preferably if the patient is cooperative then we have to try to do an MRI because we can then maybe seeing some space occupation or something and once we investigate if there are any treatable causes we have to treat those causes. If not then we have to possibly come to the diagnosis of some reverse some irreversible dementia and then possibly look at the therapeutic potentials involved and then discuss with the family and allow them to accept the diagnosis especially the family members and then possibly help them in their further day to day activities maybe help them to take a caretaker and other things. Right so I think this has been extremely comprehensive simplified and just like how I expect from experienced neurologist like you who has been in FMC and taught undergraduate student. So your discourse on dementia has been absolutely perfect the way MedPod FMC stands for in making complex topics simpler and bringing it from the mouth of experienced faculty like you. So thank you very much Reena I think this gives us an opportunity also to tell you that we will have many more such occasions where we would like your expertise where you can bring in these complex topics and make them simple for us. So thank you very much and thanks for sparing your time on a weekend coming from the area that you are serving already you are doing a tough job and to spare time for academics I think it is the best combination that we can have. So thank you very much. My pleasure sir, my pleasure any time sir thank you sir. [BLANK_AUDIO]